Treatment for Premature Ejaculation 

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What is premature ejaculation?

Several large scale studies have suggested that the most common male sexual dysfunction is premature ejaculation. One problem, as we have already seen on this website, is that there is no consistent definition of what constitutes premature ejaculation. And there is also some doubt that rapid ejaculation is abnormal - in other words, it may be a normal physiological process in the human male. Previous attempts to define premature ejaculation have been based on the number of pelvic thrust before ejaculation, or the time before ejaculation, or the level of satisfaction with sex of both the man and his partner. Startlingly, it has been shown that up to a quarter of men have routine premature ejaculation and up to a third of happily married couples have periods of premature ejaculation from time to time in the relationship. What may be even more astonishing to some is that up to 25% of young men's first attempts at sex result in ejaculation outside the vagina!

The fourth version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) defines PE as a condition in which a man regularly experiences ejaculation with only slight stimulation before he wishes to ejaculate and before, upon or very shortly after vaginal penetration. But this is meaningless if a man is with a new sexual partner or is sexually inexperienced: rapid ejaculation is the norm in such circumstances. It's also meaningless if a man is on medication which is prompting his rapid ejaculation.

So when does it become a problem? Only if it is causing a man or his partner such emotional stress or interpersonal difficulty that their lives are adversely affected. The DSM-IV diagnosis lists three other factors: 1) that PE is either a life-long condition or it can be acquired after the onset of sexual maturity and even when considerable sexual experience has been accumulated, 2) that it is either general, with all partners, or specific to one partner, or for that matter, a set of circumstances, or 3) that it can be psychologically based and the cause multi-factorial.

Obviously therefore, if we are to call a rapid ejaculation of a man with little or no sexual experience a form of premature ejaculation, this will be the most prevalent form of the condition. Young men in this category have a strong sex drive and often ejaculate before they desire to do so. Their PE is in part provoked by the emotional tension and arousal they may experience before intercourse, which is often high.

Oddly, a very common contributing factor to PE is erectile dysfunction: there may be long periods of time between sex (due to the man not having an erection very often) so that the novelty and stimulation of the situation cause an over-rapid ejaculation; the man will often lose his erection just as he ejaculates.

There are many other definitions of PE: one that we have mentioned elsewhere on this site is when ejaculation takes place in less than two minutes after penetration more than half the time when a couple make love. Another very vague definition is that sex lasts for less than one hundred thrusts after penetration. And yet another centers on a man's lack of voluntary control over his ejaculatory reflex.

Amusingly, some clinicians have suggested that ejaculation is premature if it occurs before a man's partner experiences a vaginal orgasm. As one wit responded, every man in the world would be considered a premature ejaculator if this was the case.

Physiology of ejaculation

To understand premature ejaculation, it's important to know that ejaculation and orgasm are not the same thing. Ejaculation is the result of  a short lived reflex contraction of the pelvic floor muscles. This event is precisely organized by the brain, and it's an event which involves many different neural inputs and proceeds in a set sequence. The brain responds to sexual sensory input by provoking the sympathetic nervous system into first creating the emission phase of ejaculation - where semen, made up of fluid from both the prostate gland and the seminal vesicles, is passed into the base of the urethra. The expulsion phase of ejaculation takes place when semen is propelled out of the urethra by contraction of the bulbocavernosus and the levator ani muscles - these are elements of the pelvic floor musculature. As you know, this sequence of events is often called an orgasm but in reality orgasm is the sensation produced by the pulsation of the muscles of the pelvic floor, and this need not be accompanied by an ejaculation (see here for a clear explanation of the difference between orgasm and ejaculation. Another, rather different, view of this process is described here: Jack Johnston on male/female/couple multiple orgasm).

Retrograde ejaculation and other ejaculation problems

A man may find that he has an orgasm with no ejaculation. It is not possible to have ejaculation without orgasm, for obvious reasons (see above). Retrograde ejaculation, when semen is not expelled but passes backwards into the bladder, most commonly occurs in men after prostate surgery or damage to the nerves of the pelvic area. Some medications cause retrograde ejaculation - including some new drugs designed to treat symptoms of prostate blockage. This is a sensitive set of events, very susceptible to disruption, and so there are many reasons why a man's ejaculatory reflex may go wrong. Among these are medications such as amitriptyline and tranquillsers. Many recreational drugs like alcohol can also create the conditions for retrograde ejaculation. Many doctors do not know these medications may interfere with ejaculation.

A new development in the research surrounding premature ejaculation is the idea that premature ejaculation is related to hypersensitivity of the nerves leading to the penis  - though what this means in practice is somewhat questionable.

Treatments for premature ejaculation

What you think of as premature ejaculation depends on what you want from sex. Some men can make love for up to fifteen minutes but still think they come prematurely. conversely, other men come after one minute but still feel their sex life is fine. Often the most effective treatment for premature ejaculation is information. Simply discussing premature ejaculation with a man and his partner may help them to understand that they do not have a problem. Alternatively, they may try some medication which slows down ejaculation. This treatment can be effective.

PE treatment has often included psychotherapy or sex therapy. The stop/start technique, also known as the "squeeze" technique, where the tip of the penis was squeezed to reduce arousal and ward off ejaculation, was a mainstay of this approach. This treatment is now pretty much discredited. Other treatments included local anesthetic applied to the penis to dull sensation: these are totally ineffective for both the man and his partner (who may develop a numb vagina!).

Other treatments: SSRIs and other antidepressants

Men who take antidepressants can delay ejaculation for a longish time, a fact which focused research on how these drugs might be used as treatment for premature ejaculation.

Tricyclic antidepressants can dramatically increase the period between penetration and ejaculation. But sadly they can also cause sexual dysfunction, headaches and nausea. Selective serotonin reuptake inhibitors (SSRIs) including fluoxetine, sertraline and paroxetine have been used, either officially or unofficially, as a treatment for premature ejaculation and have become very popular. Since it now appears that effective treatment for premature ejaculation is possible, research will no doubt continue

However, a warning if you decide to use SSRIs for treating your own premature ejaculation! Most men who do this try the drug without first telling their partners. And since the drug produces a significant increase between penetration and ejaculation, your partner will probably reach the conclusion you must be having an affair! (Which is, after all, one reasonable explanation for reduced libido and increased sexual latency.)

Furthermore, a lot of men stop using the drug after a short period of time because they find they are perfectly happy to ejaculate quickly. It seems that long lasting lovemaking is not everyone's real desire!

SSRIs have their effect by producing an increase in the amount of serotonin available to the central nervous system. There are some herbal compounds which have a similar effect - they work by increasing levels of the natural precursor of serotonin in the body. Such serotonin precursors supply the building blocks needed for the conversion of L-5-hydroxytrypophan (L-5-HTP) in the diet into serotonin in the body.

Herbal treatments for premature ejaculation

Anxiety is always seen in men with premature ejaculation, especially if they are at the start of their sexual career. Sexually inexperienced men may be stressed and over-excited, and the result of this over-arousal may well be premature ejaculation. Natural therapists use extract of Passiflora coerulea (chrysin) to reduce anxiety - the mechanism is similar to Valium®. This is a natural product (a bioflavinoid, in fact) that does not produce sedation or muscle relaxation.